Transcript/School Information Request

Page 1 of 1

For Rush-Henrietta graduates in need of a transcript, please complete the following information. Please allow five business days to process your request. Current students should speak with Lou Ann Leatzaw in the high school Counseling Office.

1.	Name

2.	Name Used in High School (if different)

3.	Year of Graduation

4.	(Or Year You Left the District)

5.	Date of Birth

6.	What information are you requesting?
	What information are you requesting? Transcript Immunizations Record Special Education Reports Entire File

7.	How you like to receive the information?
	How you like to receive the information? Mail it to my college or job Mail it to my house Fax it Will pick it up

8.	What address or fax number should Rush-Henrietta use to send the information? Please include name of university or employer, if applicable.

9.	My address is:

10.	My phone number is:

11.	Were you involved in any special programs, i.e. SCORE, special education, etc.?
	Were you involved in any special programs, i.e. SCORE, special education, etc.? Yes No

12.	If you need special education reports, please select what you need:
	If you need special education reports, please select what you need: IEP Medical Reports Psychoeducational Report Social History